Oral oxycodone plus intravenous acetaminophen versus intravenous morphine sulfate in acute bone fracture pain control: a double-blind placebo-controlled randomized clinical trial

Objectives

Bone fracture is a common cause of acute pain in emergency and orthopedics departments. Targeting the multifaceted mechanisms of pain with combinations of multiple analgesics (multimodal analgesia) can increase the pain control efforts efficacy and decrease the adverse effects of each medication.

Methods

One hundred and fifty-three patients with acute bone fracture were randomly allocated to two groups receiving intravenous morphine sulfate (74 patients) or oral oxycodone plus intravenous acetaminophen (79 patients). Pain scores and drugs’ adverse effects were assessed 10, 30 and 60 min after treatment.

Results

Pain scores were similar between groups before, 30 and 60 min after medication but patients in morphine sulfate group experienced less pain 10 min after medication. Eight (10.8 %) patients in morphine sulfate group and 26 (32.9 %) patients in acetaminophen/oxycodone group experienced nausea that was statistically significant higher (P value = 0.001). Itching was seen in 12 (15.1 %) patients of acetaminophen/oxycodone group and three (4.0 %) patients of patients in morphine sulfate group (P value = 0.02).

Conclusion

Intravenous acetaminophen plus oral oxycodone is as effective as intravenous morphine sulfate in acute pain control in emergency department but with a less desirable safety profile.     

持续静脉输注利多卡因用于术后镇痛的研究进展

外科手术后患者疼痛的发生率较高,不仅延缓术后康复,也降低术后生活质量。近年来,越来越多的研究表明围术期持续静脉输注利多卡因有助于减轻术后疼痛,减少阿片类镇痛药物的使用,并促进术后康复。本文将从静脉输注利多卡因的镇痛机制、减轻术后疼痛的作用以及静脉利多卡因的输注策略等方面进行详细阐述,以期为静脉输注利多卡因在术后镇痛中的应用提供参考。     

Effects of Intravenous Versus Epidural Lidocaine Infusion on Pain Intensity and Bowel Function After Major Large Bowel Surgery: a Double-Blind Randomized Controlled Trial

Background

We compared the effects of intravenous lidocaine (IVL) with lumbar epidural lidocaine analgesia (LEA) on pain and ileus after open colonic surgery.

Methods

Between December 2011 and February 2013, 60 patients were randomly allocated to IVL, LEA, or control group. The IVL group received intraoperatively lidocaine 2 % intravenously (1.5 mg/kg bolus, 2 mg/kg/h infusion) and normal saline (NS) epidurally. The LEA group received lidocaine epidurally (1.5 mg/kg bolus, 2 mg/kg/h infusion) and NS intravenously. The control group received NS both intravenously and epidurally, as bolus and infusion. All NS volumes were calculated as if containing lidocaine 2 % at the aforementioned doses. We assessed pain intensity at rest/cough at 1, 2, 4, 12, 24, and 48 h postoperatively (numerical rating scale 0–10), 48-h analgesic consumption, and time to first flatus passage.

Results

Data from 60 patients (20 per group) were analyzed. The IVL group had significantly lower pain scores at rest and cough compared to LEA or control group only at 1, 2, and 4 h postoperatively (P?P?>?0.05).

Conclusions

Compared with LEA-lidocaine or placebo, intravenous lidocaine offered no clinically significant benefit in terms of analgesia and bowel function.     

Transversus abdominis plane blocks for rescue analgesia following Cesarean delivery: a case series

Purpose

The role of routine transversus abdominis plane (TAP) blocks at the time of surgery for Cesarean delivery analgesia is uncertain. Previous studies have shown no additional analgesic benefit in patients receiving intrathecal morphine. We present a series of three cases where TAP blocks were used for rescue analgesia in patients who had severe post-Cesarean delivery pain after a standard spinal anesthetic containing bupivacaine 12 mg, fentanyl 10 μg, and morphine 200 μg.

Clinical features

All three women experienced severe incisional pain in the postanesthetic care unit (PACU) after offset of spinal anesthesia. When the pain did not subside with intravenous opioids, the women were offered either additional intravenous opioids or a TAP block. They chose the latter. Bilateral TAP blocks were performed in a sterile posterior approach under ultrasound guidance with 0.375% ropivacaine 20 mL with epinephrine 1:400,000. All three patients experienced significant pain relief that lasted 10-19 hr and allowed for a timely discharge from the PACU.

Conclusion

These cases show that TAP blocks may play a valuable role as a rescue analgesic technique rather than as a routine preemptive block for all Cesarean delivery patients. Use of TAP blocks reduced the need for escalating intravenous opioid doses and potential maternal opioid-related side effects. Rescue TAP blocks should be considered after Cesarean delivery when intrathecal morphine does not provide adequate pain relief or for early breakthrough pain after offset of spinal anesthesia.     

Lidocaine infusion has a 25% opioid-sparing effect on background pain after burns: A prospective,randomised, double-blind,controlled trial

BackgroundThe pain of a burn mainly results from the inflammatory cascade that is induced by the injured tissue, and is classified as background, breakthrough, procedural and postoperative pain. High doses of opioids are usually needed to treat background pain, so its management includes a combination of types of analgesia to reduce the side effects. Lidocaine given intravenously has been shown in two small, uncontrolled studies to have an appreciable effect on pain after burns.ObjectivesIn this prospective double-blind controlled trial we aimed to examine and quantify the opioid-sparing effect of a continuous infusion of lidocaine for the treatment of background pain during the early period after a burn.MethodsAdult patients injured with burns of >10 total body surface area burned (TBSA%) and treated with a morphine based patient-controlled analgesia device (PCA) were randomised to have either lidocaine infusion starting with a bolus dose (1 mg lidocaine/kg) followed by continuous infusion (180 mg lidocaine/hour) or a placebo infusion, for seven consecutive days. Total daily consumption of opioids (mg) and amount of pain (visual analogue score, VAS) were recorded.ResultsWe included 19 patients, 10 of whom were given a lidocaine infusion. There were no differences between groups in VAS, TBSA%, time of enrolment to the study since the initial burn, or duration of hospital stay. The opioid consumption in the lidocaine group declined by roughly 25% during the period of the study.ConclusionAn intravenous infusion of lidocaine was safe and had an opioid-sparing effect when treating background pain in burns.     

Inhibition of postoperative pain by continuous low-dose intravenous infusion of lidocaine

Intravenous lidocaine has been reported previously to inhibit postoperative pain when given either as single injections or as short infusions in amounts usually causing adverse reactions. To determine the efficacy of a continuous low-dose (2 mg/kg) intravenous infusion of lidocaine, postoperative pain (visual analogue pain scale) and the requirements for postoperative analgesics were measured in a double-blind randomized trial in 20 patients after cholecystectomy. Lidocaine infusion was started 30 min before the operation and continued for 24 hr after surgery (n = 10). Saline was infused in a comparable group of ten patients. The lidocaine-treated patients had significantly lower pain scores during the first day after surgery (P less than 0.001) and required significantly less meperidine during the first (P less than 0.02) and second postoperative days (P less than 0.01). No adverse reactions to lidocaine were observed. Whole blood levels of lidocaine ranged between 1 and 2 micrograms/ml. The results suggest that low-dose continuous infusions of lidocaine decrease the severity of postoperative pain and are devoid of side effects.     

Chronic post-traumatic neuropathic pain of brachial plexus and upper limb: a new technique of peripheral nerve stimulation

The aim of the study was to evaluate the effect on pain relief in patients with peripheral neuropathic pain after brachial plexus injuries using an implanted peripheral nerve stimulator applied directly to the nerve branch involved into the axillary cavity. Seven patients with post-traumatic brachial plexus lesions or distal peripheral nerve complaining of severe intractable chronic pain were enrolled in a single-centre, open-label trial. Conventional drugs and traditional surgical treatment were not effective. Patients underwent careful neurological evaluation, pain questionnaires and quantitative sensory testing (QST). Surgical treatment consists of a new surgical technique: a quadripolar electrode lead was placed directly on the sensory peripheral branch of the main nerve involved, proximally to the site of lesion, into the axillary cavity. To assess the effect, we performed a complete neuroalgological evaluation and QST battery after 1 week and again after 1, 6 and 12 weeks. All patients at baseline experienced severe pain with severe positive phenomena in the median (5) and/or radial (2) territory. After turning on the neuro-stimulator system, all patients experienced pain relief within a few minutes (>75 % and >95 % in most), with long-lasting pain relief with a reduction in mean Numerical Rating Scale (NRS) of 76.2 % after 6 months and of 71.5 % after 12 months. No significant adverse events occurred. We recommend and encourage this surgical technique for safety reasons; complications such as dislocation of electrocatheters are avoided. The peripheral nerve stimulation is effective and in severe neuropathic pain after post-traumatic nerve injuries of the upper limbs.     

Pain therapy in pediatric oncology: pain experience, drugs and pharmacokinetics

Paediatric cancer patients often experience fear and pain from the disease but also in connection with the necessary diagnostic and therapeutic procedures. The treatment of pain is a priority for all patients, especially for critically ill children because of their vulnerability and limited understanding. The experience of pain is always subjective and depends on the age, the pain experience and the environment.In contrast to adults, it is often difficult to detect character of pain, pain intensity and pain localization in very young patients. Diagnostic and therapeutic procedures are performed in analgosedation for a given drug scheme by a pediatrician experienced in intensive care.In addition, a local anesthetic for an access system/lumbar punctures in the form of EMLA? patch is to be carried out. A rapid and effective treatment of pain and appropriate analgesia can prevent patients from being traumatized.For severe pain, malignancy- or chemotherapy-induced (eg. mucositis WHO grade 3 and 4) initial use of strong opiates is recommended instead of climbing the WHO ladder. For strong opiates, there is no maximum dose, as long as a dose increase leads to clinically observable increase in analgesia, without severe side effects. Patient-controlled analgesia with morphine as continuous subcutaneous or intravenous infusions and the possibility of a bolus injection is suited for children aged 6 years. A measurement of O2-saturation is essential during this infusion. Prophylactic approaches also must be used consistently in regard to the acute side effect of opiate treatment. Good experience, we have also made a non-drug therapy, e.g. personnel/physical affection, cuddling, massage, etc.The choice of analgesia depends on the nature and cause of pain. In neuropathic pain or phantom pain coanalgetics should be used to effectively treat pain in young patients. Different analgesic treatment approaches of the appropriate indications and adverse effects are presented. A particular challenge for the pediatrician is the sufficient and adequate pain therapy in palliative care.     

Intranasal lidocaine plus naphazoline nitrate improves surgical conditions and perioperative analgesia in septorhinoplasty surgery

Background

Septorhinoplasty is a traumatic procedure that is associated with epistaxis and postoperative pain. The primary objective of this randomized double-blind controlled trial was to determine whether intranasal 5% lidocaine plus naphazoline decreases postoperative pain and lessens the use of rescue analgesics.

Methods

After induction of general anesthesia and laryngeal topical anesthesia with 5% lidocaine, 28 adult patients, scheduled to undergo septorhinoplasty, were randomly assigned to one of two groups, either topical intranasal saline 20 ml (control group) or intranasal 5% lidocaine plus naphazoline solution 0.2 mg ml^?1 (lidocaine group). The perioperative dose of sufentanil, the mean end-tidal concentration of isoflurane, and surgeon satisfaction with the operative field were recorded. In the lidocaine group, plasma lidocaine concentrations were sampled 15, 20, 25, 35, 45, and 55 min after induction of anesthesia. Visual analogue scale pain scores were recorded 30, 60, 90, and 120 min after the patients arrived in the postanesthesia care unit and 24 h after surgery. Consumption of morphine rescue analgesia and the occurrence of any side effects were recorded at the end of the 24-h study period.

Results

The intranasal lidocaine-naphazoline application decreased isoflurane requirements [median values: 0.8% (0.7–1.5) vs. 1.2% (0.9–1.8), respectively; P = 0.04] and enhanced surgical conditions. Patients in the lidocaine group experienced less postoperative pain than the control group [1 h after surgery: median values of visual analogue scale: 0 (0–20) vs. 50 (30–80), respectively; P = 0.001], and they required fewer doses of subcutaneous morphine. Total plasma concentrations of lidocaine remained below 4 μg ml^?1 throughout the study period.

Conclusions

Intranasal lidocaine plus naphazoline is a simple and efficient technique for decreasing intra- and postoperative pain and for lessening rescue analgesic requirements in the postoperative period after septorhinoplasty. Toxic plasma concentrations of lidocaine were not reached.     

Pain control with epidural anesthesia for uterine artery embolization

BACKGROUND: To reduce the severity of post procedure pain associated with uterine artery embolization (UAE) for leiomyomata, we used continuous infusion of low concentration ropivacaine through an epidural catheter. METHODS: Thirteen patients for UAE were evaluated. In a patient without indication for epidural anesthesia, the pain was controlled with intermittent morphine infusion. Other patients had post procedure pain managed with 10 ml bolus of 1% lidocaine and continuous infusion of 0.2% ropivacaine at 5 ml x hr-1 for 16 hours. RESULTS: The patient complained of severe pain just after UAE and required epidural lidocaine. Then, we started to infuse lidocaine or ropivacaine just before starting UAE. Among these cases, 9 patients required extra pain control using NSAIDs as a rescue. Only three patients required no medication except epidural analgesia. CONCLUSIONS: Continuous infusion of 0.2% ropivacaine at a rate of 5 ml x hr-1 is not enough for pain management after UAE.     

Clinical Efficacy of Intravenous Lidocaine for Thyroidectomy: A Prospective,Randomized, Double-Blind,Placebo-Controlled Trial

Background

Systemic lidocaine has analgesic and anti-inflammatory effects. The purpose of this prospective, randomized, double-blind study was to evaluate the effects of intravenous lidocaine on pain following thyroidectomy.

Methods

Fifty-eight adult patients scheduled for total thyroidectomy were randomly allocated to receive a 1.5 mg/kg lidocaine bolus followed by a 2 mg/kg/h infusion during surgery, or the same volume of normal saline (control). After thyroidectomy, we evaluated postoperative pain, nausea, fentanyl consumption, frequency of pushing the button (FPB) for patient-controlled analgesia (PCA), High-sensitivity C-reactive protein (hs-CRP) in serum, and patient satisfaction scores regarding the recovery process.

Results

Postoperative pain and nausea scores were significantly lower in the lidocaine group for the first 4 h following thyroidectomy, compared to the control group. Fentanyl consumption and FPB for the PCA were also significantly reduced in the lidocaine group for 4 h following thyroidectomy, and hs-CRP was significantly less in the lidocaine group at postoperative days 1 and 3. Furthermore, satisfaction scores were significantly higher in the lidocaine group compared to the control group.

Conclusions

Intravenous lidocaine effectively reduced postoperative pain and nausea following thyroidectomy as well as improved the quality of recovery. Trial registration number: Clinicaltrials.gov NCT01608360.

     

围术期静脉输注利多卡因在胸科手术中的应用进展

利多卡因是一种酰胺类局部麻醉药,有临床证据表明,围术期静脉输注利多卡因在抗炎、镇痛、抗肿瘤及器官保护等方面具有积极作用。胸科患者术后疼痛程度较重,术后肺部并发症及认知功能障碍发生率较高,且这些不良反应及并发症与围术期炎症反应密切相关,围术期静脉输注利多卡因在不同研究中被证明具有减轻以上不良反应及并发症的效果。因此,本文主要综述围术期静脉输注利多卡因在胸科手术中的应用现状,并对相关作用机制进行探讨,旨在为胸科手术围术期麻醉管理提供优化方案。     

The influence of a bupivacaine and fentanyl epidural infusion after epidural fentanyl in patients allowed to ambulate in early labor

Epidural fentanyl after a lidocaine and epinephrine test dose provides adequate analgesia and allows for ambulation during early labor. This study was designed to determine the influence of an epidural infusion of bupivacaine plus fentanyl administered after initiation of epidural labor analgesia with fentanyl. Specifically, we evaluated whether there is an increase in motor block or an increased time to request for further analgesic medication. Fifty-one laboring primigravid women at <5 cm cervical dilation who requested epidural analgesia were enrolled. After a 3-mL epidural test dose of 1.5% lidocaine with epinephrine (5 microg/mL), patients received fentanyl 100 microg via the epidural catheter. They then randomly received either an infusion (10 mL/h) of 0.0625% bupivacaine with fentanyl (3 microg/mL) or an infusion of preservative-free saline. After the administration of the initial analgesic, pain scores and side effects were recorded for each patient at 10, 20, and 30 min, every 30 min thereafter, and at the time of request for additional analgesic medication, by an observer blinded to the technique used. There were no demographic differences between the two groups. The mean duration of analgesia (time from initial dose to request for additional analgesia) was increased in the group that received a continuous infusion of bupivacaine and fentanyl compared with the Saline group (198 +/- 86 vs 145 +/- 50 min; P < 0.009). Side effects were similar between the two groups. No patient in either group experienced any detectable motor block. Fourteen patients chose to ambulate in the Saline group, and 12 patients chose to ambulate in the Infusion group. In early laboring patients, a continuous infusion of 0.0625% bupivacaine infusion with fentanyl (3 microg/mL) prolonged the duration until top-up was required, after epidural fentanyl 100 microg after a lidocaine and epinephrine test dose, and did not cause any clinically detectable motor block. IMPLICATIONS: A 0.0625% bupivacaine and fentanyl (3 microg/mL) infusion, when added to epidural fentanyl (100 microg), prolongs the analgesic duration without increasing motor block in women in early labor.     

Low-dose gabapentin as useful adjuvant to opioids for neuropathic cancer pain when combined with low-dose imipramine

Purpose

Painful neuropathic conditions of cancer pain often show little response to nonopioid and opioid analgesics but may be eased by antidepressants and anticonvulsants. Although gabapentin is effective in the treatment of neuropathic pain in patients with cancer, some patients experience intolerable side effects sufficient to warrant discontinuation. The aim of this study was to see whether low-dose gabapentin is effective in treating cancer-related neuropathic pain when combined with low-dose imipramine.

Methods

Fifty-two cancer patients diagnosed as having neuropathic pain were allocated into four groups: G400-I group took gabapentin 200 mg and imipramine 10 mg every 12 h orally; G400 group took gabapentin 200 mg every 12 h orally; G800 group took gabapentin 400 mg every 12 h orally; I group took imipramine 10 mg every 12 h orally.

Results

Low-dose gabapentin–imipramine significantly decreased the total pain score and daily paroxysmal pain episodes. Several patients developed mild adverse symptoms in the four groups, and three patients discontinued treatment due to severe adverse events in the G800 group.

Conclusion

Low-dose gabapentin–antidepressant combination with opioids was effective in managing neuropathic cancer pain without severe adverse effects.     

Quality of lidocaine analgesia with and without midazolam for intravenous regional anesthesia

Purpose

Midazolam has analgesic effects mediated by gamma aminobutyric acid-A receptors. This study was designed to evaluate the effect of midazolam on anesthesia and analgesia quality when added to lidocaine for intravenous regional anesthesia (IVRA).

Methods

Forty patients undergoing hand surgery were randomly assigned to two groups to receive IVRA. The control group received 3 mg/kg lidocaine 2% w/v diluted with saline to a total volume of 40 ml, and the midazolam group received an additional 50 μg/kg midazolam. Sensory and motor block onset and recovery times, tourniquet pain, intraoperative analgesic requirements, sedation, and anesthesia quality were recorded. Postoperative pain and sedation scores, time to first analgesic requirements, analgesic use in the first 24 h, and side effects were noted.

Results

Sensory and motor block onset and recovery times did not differ significantly between groups. Tourniquet pain scores were lower at 10, 15, 20, and 30 min (P < 0.0001) in the midazolam group. Three (15%) patients in the midazolam group required fentanyl for tourniquet pain compared with thirteen (65%) patients in the control group (P = 0.02). Patients in both groups received fentanyl once. Midazolam group showed that significantly less patients required diclofenac for postoperative analgesia (P < 0.01) and analgesic-free period during first postoperative 24 h was significantly longer (726.8 ± 662.8 min vs. 91.0 ± 35.9 min, P < 0.0001). Postoperative pain scores were lower (P < 0.0001) and sedation scores higher (P < 0.05) for the first 2 h in the midazolam group.

Conclusion

Addition of midazolam to lidocaine for IVRA improves anesthesia quality and enhances intraoperative and postoperative analgesia without causing side effects.     

Lack of Impact of Intravenous Lidocaine on Analgesia, Functional Recovery, and Nociceptive Pain Threshold after Total Hip Arthroplasty

Background: The analgesic effect of perioperative low doses of intravenous lidocaine has been demonstrated after abdominal surgery. This study aimed to evaluate whether a continuous intravenous low-dose lidocaine infusion reduced postoperative pain and modified nociceptive pain threshold after total hip arthroplasty.

Methods: Sixty patients participated in this randomized double-blinded study. Patients received lidocaine 1% (lidocaine group) with a 1.5 mg/kg-1 intravenous bolus in 10 min followed by a 1.5 mg [middle dot] kg-1 [middle dot] h-1 intravenous infusion or saline (control group). These regimens were started 30 min before surgical incision and stopped 1h after skin closure. Lidocaine blood concentrations were measured at the end of administration. In both groups, postoperative analgesia was provided exclusively by patient-controlled intravenous morphine. Pain scores, morphine consumption, and operative hip flexion were recorded over 48 h. In addition, pressure pain thresholds and the extent of hyperalgesia around surgical incision were systematically measured at 24 and 48 h.

Results: In comparison with the placebo, lidocaine did not induce any opioid-sparing effect during the first 24 h (median [25-75% interquartile range]; 17 mg [9-28] vs. 15 mg [8-23]; P = 0.54). There was no significant difference regarding the effects of lidocaine and placebo on pain score, pressure pain thresholds, extent in the area of hyperalgesia, and maximal degree of active hip flexion tolerated. Mean plasma lidocaine concentration was 2.1 +/- 0.4 [mu]g/ml.     

Adjuvant use of intravenous lidocaine for procedural burn pain relief: a randomized double-blind, placebo-controlled, cross-over trial

Background

Pain is a major issue for patients with severe burn. High dose intravenous opioids form the mainstay of procedural burns pain management; however it was suggested that intravenous lidocaine assists with minimising the pain experience. This study aimed to evaluate whether intravenous lidocaine improved analgesic efficacy and decreased opioid consumption during a burn wound care procedure.

Methods

A prospective double-blind randomized crossover study compared intravenous lidocaine versus placebo alongside patient controlled analgesia (PCA) in 45 patients with severe burn undergoing wound care procedures (i.e. dressing change ± debridement) on two consecutive days. Subjects were randomised to either the intervention or control condition on the first dressing day, and received the alternate condition on the second dressing day. During the intervention condition, subjects received lidocaine of 1.5 mg/kg/body weight followed by two boluses of 0.5 mg/kg at 5-min intervals followed by a continuous infusion. During the control condition, 0.9% sodium chloride was administered at an equivalent volume, dose and rate to that of lidocaine. Primary end points included pain intensity as measured by verbal rating scale (VRS), time to rescue analgesia, opioid requests and consumption and overall anxiety and level of satisfaction.

Results

Changes in the VRS score was significantly lower for lidocaine [difference (95% CI) = 0.36 (0.17 − 0.55)] as compared to placebo. However, there were no significant clinical or statistical differences regarding the effects of lidocaine and placebo on opioid requests and consumption, anxiety or level of satisfaction during the first and second dressing procedures.

Conclusions

In this study, the clinical benefit of intravenous lidocaine for pain relief during burn wound dressing changes in terms of overall pain scores and opioid consumption was unremarkable. Further investigations using different lidocaine regimes for the management of procedural burn pain are warranted.     

Continuous intrathecal morphine treatment for chronic pain of nonmalignant etiology: long-term benefits and efficacy

BACKGROUND: To analyze, prospectively, the long-term effects of continuous intrathecal morphine infusion therapy in 16 patients with chronic nonmalignant pain syndromes.METHODS: Twenty-five patients with severe, chronic, nonmalignant pain that had proven refractory to conservative management were considered candidates for trial of intrathecal spinal morphine. Sixteen patients achieved more than 50% pain relief after a trial period of intrathecal morphine infusion. They were implanted with fully implantable and programmable pumps through which morphine was delivered intrathecally on a continuous basis. These patients were followed prospectively and underwent careful evaluation of their functional and mental status, and pain intensity measurements using standardized techniques before treatment and every 6 months thereafter in the follow-up period. The follow-up period ranged from 13 months to 49 months (mean 29.14 months +/- 12.44 months) for the patients who had implanted morphine pumps.RESULTS: The mean morphine dosage initially administered was 1.11 mg/day (range 0.2--6.5 mg/day); after 6 months, it was 3.1 mg/day (range 0.4--8.75 mg/day). In long-term observation, no patient had a constant dosage history. The patients who received intrathecal morphine for longer than 2 years all showed an increase in morphine dosage to more than 10 mg/day. The best long-term results were seen with deafferentation pain and mixed pain, with 75% and 61% pain reduction (visual analog scale), respectively. Nociceptive pain patients had best pain relief initially (78% pain reduction) but it tended to decrease over the follow-up period to 57% pain reduction at final follow-up. The average pain reduction for all groups after 6 months was 67.5% and at last follow-up, it was 57.5%. Ten patients were satisfied with the delivery system and eleven reported improvement in their quality of life. In two patients, morphine was not able to adequately control the pain without producing undesirable side effects requiring the addition of clonidine to their infusion medication. In this series, 12 patients were considered successes and 4 patients were considered failures. In two patients, the intrathecal opioid therapy was unable to produce satisfactory pain relief and in the other two patients the pumps had to be explanted because of intolerable side effects.CONCLUSIONS: In our experience, the administration of intrathecal opioid medications for nonmalignant pain is justified in carefully selected patients.     

Gamma knife radiosurgery for trigeminal neuralgia: experience at the Barrow Neurological Institute

Forty-three patients with trigeminal neuralgia (TN) unresponsive to pharmacologic treatment and/or prior invasive procedures underwent stereotactic radiosurgery with the Gamma Knife (GK). Outcome was evaluated by a standardized questionnaire mailed to each patient. The mean follow-up was 9 months. Fifteen patients (35%) reported no trigeminal pain and were no longer taking medication. Three patients (7%) experienced occasional pain, but were no longer taking medication. In 15 patients (35%), pain improved and was adequately controlled by medication, often in lower dosages than preoperatively. Pain was reduced in 9 patients (21%), but their symptoms were still inadequately controlled by drug therapy, and 1 patient (2%) reported no pain relief after treatment. Three patients (7%) described new facial numbness, but in none was this bothersome. GK radiosurgery for TN appears to have minimal morbidity, although the success rate may be slightly lower than that of other operative procedures. More patients and longer follow-up are needed before drawing final conclusions regarding efficacy and complications.     

Efficacy of endotracheal lidocaine administration with continuous infusion of remifentanil for attenuating tube-induced coughing during emergence from total intravenous anesthesia

Purpose

Although attenuation of tube-induced coughing is necessary in specific types of surgery, the best method for such attenuation is still unclear. We studied the combined intervention of endotracheal lidocaine and intravenous remifentanil compared to intravenous remifentanil alone with respect to coughing during emergence from anesthesia.

Methods

We examined 60 ASA 1–2 patients (age, 20–69 years) undergoing tympanoplasty under general anesthesia. Anesthesia was induced with propofol, remifentanil, and rocuronium. The trachea was intubated using a laryngotracheal instillation of topical anaesthetic (LITA) tracheal tube. Anesthesia was maintained with propofol and remifentanil (0.1–0.3 μg/kg/min). Propofol was discontinued and remifentanil (0.1 μg/kg/min) was continued at the end of the operation. Patients were randomly allocated to the lidocaine (n = 30) and control groups (n = 30). We administered 3 ml 4 % lidocaine via the LITA tube to patients in lidocaine group at the end of the operation. The trachea was extubated when the patient regained consciousness and followed orders. Coughing was evaluated using a 4-point scale by an observer who examined the video records at extubation.

Results

Fewer patients in lidocaine group (8 of 30) than in control group (18 of 30, p < 0.01) coughed. Fewer patients in lidocaine group (2 of 30) than in control group (12 of 30, p < 0.01) had moderate or severe cough (scale 2 or 3).

Conclusions

This study is consistent with the finding that endotracheal lidocaine administration and continuous infusion of remifentanil before extubation is useful to prevent coughing on emergence from anesthesia.